Although the widespread use of testing is largely a phenomenon of the 20th century, it has been noted that rudimentary forms of testing date back to at least 2200 B.C., when the Chinese emperor had his officials examined every third year to determine their fitness for office

In 1884, London hosted the International Health Exhibition.

Francis Galton took advantage of this opportunity to set up his anthropometric laboratory. He stated that the purpose of this laboratory was to “show the public the simplicity of the instruments and methods by which the chief physical characteristics of man may be measured and recorded.” The laboratory was an interactive walk-through in which physical characteristics such as height, weight, and eyesight, would be measured for each subject after payment of an admission fee

As an investigator of the human mind, he founded psychometrics (the science of measuring mental faculties

The first handgrip dynamometer, the Régnier dynamometer, was invented and built by Edme Régnier (Régnier, 1807)

When to perform an FCE

Normal return to activity

1. Injury (at work, in car, at home)
2. Physician provides note to stay off work (restrictions)
3. Treatment (rest, physio, chiro etc.)
4. Recovery
5. Physician clears return to activity (removes restrictions)

Complicated return to activity

1. Injury
2. Physician note to stay off work (restrictions)
3. Treatment
4. Partial Recovery
5. PDA - determine physical demand requirement
6. FCE - measure ability to perform requirements
7. Physician clears return to activity

Historically, return-to-work decisions were based upon diagnoses and prognoses of physicians, but did not include objective measurements of an individual’s functional abilities. Most physicians are not trained to assess the full array of human functional abilities required for comprehensive disability determinations or return to work recommendations. The physician or treating provider determines diagnosis and medical prognosis, but should rely on functional testing to more objectively identify an individual’s functional abilities and limitations rather than their use of estimates, commonly called restrictions.

In an evidence-based medical model, measurements are preferable to estimates.

Stakeholders in MVA accident

1. Auto insurer (is paying for treatment and for lost wages)
2. Individual
3. Employer (needs a replacement worker)
4. Treatment provider
5. Lawyer (assisting individual)
6. Independent assessors (providing specialized information)
7. Physician

Stakeholders in workplace accident

1. Individual
2. Physician
3. Employer
4. WCB
5. Treatment provider
6. Independent assessor
7. Lawyer

Stake holders in sports injury

1. Individual
2. Sports team
3. Physician
4. LTD (Manulife, Sunlife, Great West life etc.)
5. Lawyer
6. Treatment provider
7. Independent assessor
8. Employer

Prior to starting the FCE

• Job Demands

If a job-specific FCE has been requested, the examiner needs detailed information regarding the physical requirements of the essential and marginal duties. This can be obtained from review of a job description or job analysis. In the absence of adequate information an on-site job analysis is recommended prior to the FCE to identify this information. In cases where on-site analysis cannot be performed, the Functional Capacity Examiner may rely on online job databases. These sources provide general information and may reflect a range of job demands that might not accurately reflect a specific job position. While the individual being evaluated can provide information about his job duties and requirements, this information should be confirmed with the employer. The Functional Capacity Examiner should document the source of the physical job demands in the FCE report.

Physical demands. The physical requirements made on the worker by the specific job-worker situation. There are 26 physical demands: 1) Standing; 2) Walking; 3) Sitting; 4) Lifting; 5) Carrying; 6) Pushing; 7) Pulling; 8) Climbing; 9) Balancing; 10) Stooping; 11) Kneeling; 12) Squatting (Crouching); 13) Crawling; 14) Reaching; 15) Handling; 16) Fingering; 17) Feeling; 18) Talking; 19) Hearing; 20) Tasting/Smelling; 21) Near Acuity; 22) Far Acuity; 23) Depth Perception; 24) Accommodation; 25) Color Vision; and 26) Field of Vision.

• Medical Records

Medical Records that provide background regarding the individual’s mechanism of injury or illness and subsequent treatment can provide helpful information to the Examiner. Records may include operative notes, recent diagnostic test reports, physician records, and occupational and physical therapy records

• Considerations for the Individual Being Tested

1. The individual should be medically stable, or the FCE test protocol should be administered within the safe confines of the individual’s health condition. During the FCE, the Examiner is responsible for ensuring the individual’s safety.
2. The individual must consent to participate in the FCE. A written informed consent specifically outlining the nature of the FCE is recommended. The consent should inform the individual of potential risks including but not limited to a temporary increase in symptoms, musculoskeletal soreness for several days, a temporary exacerbation of the current condition, re-injury of the affected body part, or an additional injury. The Examiner is responsible for ensuring that the individual fully understands the information presented, has an opportunity to ask questions, and all questions are answered in a manner the individual considers satisfactory
3. The Examiner should stay abreast of current evidence-based practice guidelines to ensure safe administration of functional tests. Performance of the test would compromise the individual’s safety or medical condition. As used herein, safety refers to preventing a new injury or adversely affecting an individual’s current condition. A transient increase in soreness or pain symptoms is not considered to be unsafe

FCE Design

Functional Capacity Examiners should design and/or utilize established functional tests that meet the following criteria

1. Safety. The tests should not be expected to lead to injury.
2. Reliability. The measures from the tests should produce consistent results.
3. Validity. The tests measure what they were intended to measure
4. Practicality. The time and cost involved in the design, administration, interpretation and reporting of tests should be reasonable
5. Utility. The results outlined in the FCE report should be comprehensible to non-medical readers and the results should provide useful information.

Test Components

1. Referral Review
2. Medical Record Review
3. Informed Consent
4. Intake Interview
5. Psychosocial Screening and comprehensive pain assessment
6. Physical Examination
7. Cardiovascular Respiratory Abilities testing
8. Material Handling testing
9. Non-Material Handling (coordination, flexibility and postural testing)
10. Cognitive testing
11. Work simulation (as required)
12. Post-test examination

Test Administration

Test administration should be sequenced and progressed to optimize the individual’s performance and safety. The Examiner should be aware of the reason for referral prior to commencing the FCE. The Examiner should use the initial intake interview and systems review to establish rapport with the individual and to determine the most appropriate test components to include in order to obtain the information requested. Any test that either does not provide the needed information or might place the individual at foreseeable risk of injury should be forgone. Throughout testing the Examiner should monitor the individual’s physiological, biomechanical, and psychophysical responses to activity.

Physiological monitoring includes regular assessment of heart rate for safety reasons and also as an indicator of an individual’s effort level during testing. In cases when the individual’s heart rate and heart rate response may be affected by medication or other factors revealed in the medical history such as a pacemaker, alternative monitoring should be employed. Alternatives may include the use of the Borg Rating of Perceived Exertion Scale67 as well as more reliance on respiratory rate and blood pressure. Other physiological monitoring includes, but is not limited to, cardiac rhythm, blood pressure, respiratory rate, oxygen saturation, perspiration, color, and swelling.

Biomechanical monitoring should include, but is not limited to, clinical observations of muscle recruitment, movement patterns, stance, balance, and counterbalancing68

The Examiner should monitor an individual’s symptoms during the administration of an FCE for safety and as a component of a comprehensive pain assessment. Pain may be associated with a nociceptive response from injured tissue, an anticipation of a nociceptive response from injured tissue, or an individual’s perception of threat of pain or harm. A fundamental challenge for the Examiner is to consider the degree to which psychosocial factors and symptom reports impact performance during functional testing.71 The Examiner should incorporate a comprehensive pain assessment which includes psychosocial screening, pain behavior assessment, and physiological assessment in the administration of a FCE because research demonstrates that psychosocial factors influence performance. Psychosocial factors that influence performance include but are not limited to:

1. Perceived disability
2. Kinesiophobia/Fear Avoidance Beliefs
3. Catastrophizing
4. Anxiousness/Distress/Depressed Mood
5. Self-efficacy
6. Perceived Injustice

Pain

As part of a comprehensive pain assessment, the Examiner should monitor physiological responses associated with an acute increase in pain. The Examiner should be aware of research that reports that physiological responses may be due to an increased pain stimulus or the anticipation of the pain stimulus. The Examiner should also be aware that physiological response changes can be associated with increased physical exertion during the FCE. Whether the acute physiological responses are due to exertion, anticipation of pain, or an increased pain stimulus, the evidence is clear that during an FCE there should be physiological response changes. When an individual reports an acute increase in pain during the FCE, the physiological responses monitored could include

1. Increased heart rate
2. Increased blood pressure
3. Increased breathing rate
4. Diaphoresis
5. Pupil dilatation

During testing, the Examiner should monitor pain behaviors and reported symptoms, and consider the correlation between the observed behaviors, symptom reports and clinical examination findings. Pain behaviors can include but are not limited to:

1. Facial expressions: Frowning, grimacing, distorted expression, or rapid blinking
2. Verbalizations/vocalizations: Sighing, moaning, calling out, or asking for help
3. Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, biomechanical changes/compensations/substitution patterns and other mobility changes such as inactivity or motor restlessness
4. Changes in interpersonal interactions: Aggressive, resistive, disruptive, or withdrawn
5. Changes in activity patterns: Sudden cessation of common routines
6. Mental status change: Crying, increased confusion, irritability, or distress

The Examiner may consider utilizing a pain scale with functional descriptors (functional pain scale) during the comprehensive pain behavior assessment to provide further evidence in forming an opinion about how the individual’s pain affected observed function during testing.

No single tool can be used to classify an individual’s pain report as an accurate representation of pain that affects function or an inaccurate representation of the individuals subjective pain response, and the Examiner should use a battery of the above-mentioned tools throughout the FCE to assist the examiner in determining how pain affects or does not affect the final functional abilities determination.

Effect of Pain and other Symptoms

Pain or the anticipation of pain or other symptoms may influence an individual’s performance during testing. An individual may communicate pain verbally, through facial expressions, body posture and movements. Examiners should consider the extent to which an individual’s reported pain or other symptoms impacted test performance. Significant changes in an individual’s reported pain or other symptoms that occur during or after testing should be correlated with objective changes in physical signs including, but not limited to heart rate, blood pressure, muscle spasm, joint warmth, and/or swelling. Examiners should use caution when interpreting an individual’s pain behaviors and reports since examiner bias and beliefs can impact interpretation

If it is determined that an individual’s pain and other symptoms are consistent with objective medical evidence, and the individual has demonstrated signs associated with significant effort during testing, the Examiner should adjust the final recommendations about an individual’s functional abilities and functional limitations to reflect activity levels to one that is expected to better accommodate their safe work tolerances and be sustainable over time in a productive work environment.

However, if it is determined that an individual’s pain and other symptoms are not consistent with objective medical evidence, and the individual’s test performance showed less than good effort, the Examiner should not rely on the individual’s self-reports of pain or other symptoms as a basis to adjust their functional abilities and functional limitations.

Clinical Observations

Physiological monitoring should include at a minimum heart rate and other variables such as respiratory rate, oxygen saturation, and cardiac rhythm when feasible or required for safe testing.

Biomechanical monitoring should include body mechanics including stance and counterbalancing as well as muscle recruitment patterns. This monitoring should be performed visually using predetermined categorical scales designed for the purpose

Psychophysical monitoring includes monitoring the individual’s perceived pain, other symptoms, and reported effort. Tools such as a numeric pain rating scale, visual analogue pain scale, rated perceived exertion scale, and rated perceived load scales provide an objective measure of the pain or perceived exertion

Performance or effort level

Examiners must consider the individual’s test participation and effort during the FCE, and make a determination about effort based on the preponderance of data. The determination should be based on the test endpoints (physiological, biomechanical, and psychophysical), the individual’s reported symptoms and associated behaviors, clinical examination findings, movement/performance consistency, and observed signs associated with pain.

A variety of functional testing methods have been utilized extensively in functional capacity evaluations to assess what has been reported as an individual’s “sincerity of effort.” Some of these methods include: comparing an individual’s performance from static (isometric) lift strength testing to their performance during incremental dynamic lift testing, five-rung grip testing, rapid exchange grip testing, and using the coefficient of variance statistical measure with static lift testing and grip strength testing. However, the preponderance of evidence does not support the use of the term “sincerity of effort” nor the use of these testing methods alone for classifying an individual’s performance or effort level.107-132 Examiners should understand the proper use and limitations of these testing methods and use caution when applying these methods to make a determination about an individual’s effort during functional testing. It is recommended that Examiners make determinations about effort based on the presence of physiological and biomechanical signs (i.e., heart rate, respiration rate, muscle recruitment, and consistency of movement patterns) in combination with clinical examination findings and symptom reports.

A determination regarding the individual’s effort during the FCE informs the report user the extent to which the data approximates the individual’s ability to safely participate in work and other major life activities. When determining an individual’s effort or performance level, the Examiner should also consider the scoring patterns (performance patterns). A progressive score increase (increase in performance) may suggest a learning effect or improved confidence of the individual, while a progressive score decrease (decrease in performance) may reflect fatigue or an unresolved clinical condition.

To more accurately predict an individual’s ability to safely perform work-related activities over an 8-hour period, it is recommended that Examiners utilize the following work physiology guidelines for interpreting the results of heart rate responses used for calculating percent maximum aerobic capacity:

Residual Functional Capacity

Residual Functional Capacity represents what an individual can still do despite functional limitations resulting from a medically determinable impairment(s) and impairment-related symptoms.

In determining an individual’s residual functional capacity, the Examiner should rely on objective clinical measurements and observations during content valid functional testing in combination with objective evidence gathered from a physical examination and a review of medical records. The Examiner should also consider subjective evidence gathered from multiple sources of self-reported pain and disability questionnaires along with subjective information provided by an individual.

In cases where the individual provided appropriate observable signs of effort or predictable compensatory strategies related to diagnosis and physical impairments along with pain behavior, the Functional Capacity Examiner should consider the individual’s subjective reports of pain, other symptoms and limitations when arriving at a final conclusion regarding functional abilities and limitations. For example, if an individual reports an increase in pain or other symptoms in conjunction with a functional activity circuit, the individual’s tolerance with the specific activities that caused the increase in pain or other symptoms should be adjusted to a lower functional level in order to ensure the individual’s activity tolerance on a safe and dependable basis. In cases where an individual consistently performs at a low activity level and has a high symptom-focus, the results reflect the individual’s activity tolerance or minimal functional abilities.

Reporting

The FCE report is the product produced by the Examiner. The report should be clearly written and easily understood by nonmedical individuals. The use of abbreviations and jargon should be avoided. The results should be reported using generally accepted terminology as defined in this Guideline and supporting references. Each page should be numbered. If there are intentional blank spaces or pages in the report, it should be noted that this is intentional. The Examiner’s name and specialty should be identified. Often, a summary of findings listing functional abilities, functional limitations and the individual’s performance participation precedes the detailed report data, to facilitate application of the results. The report should contain the following components4, but not necessarily in this order:

1. Introduction: the reason(s) for the FCE/type of FCE performed
2. Individual’s demographic and background information.
3. List and summary of medical records
4. Summary of information from the individual interview.
5. Summary of results of activities of daily living or psychometric questionnaires with discussion of the significance of the results
6. Clinical examination findings
7. Results of the functional tests including test endpoint reached and physiological, biomechanical, and psychophysical results
8. Discussion of individual’s performance level (effort and consistency) and pain behaviors
9. Summary of functional abilities and limitations (if requested identification of accommodations to lesson impact of any functional limitations)
10. If job or occupation specific FCE, compare individual’s abilities with job and/or occupational demands.
11. Recommendations

Recommendations detail

1. Transitional work recommendations
2. If requested, treatment recommendations
3. If requested, an opinion statement defining the functional limitations as temporary or permanent
4. If temporary, functional re-testing may be done at a later date to reassess safe work tolerances, functional limitations, and restrictions,
5. If permanent, the results of the FCE should be considered applicable for a range of time up to 6 months. This is dependent on the nature of the injury/illness, and whether any other health condition, injury or other factor changes the individual’s health status or lifestyle. In the absence of any substantive change in the individual’s health status or lifestyle, a repeat FCE to update the individual’s functional status is recommended

Functional impairment. The loss of functional ability to safely perform occupational and/or job specific activities. This term is sometimes but not always associated with the severity of anatomic/physiologic impairment obtained from an impairment evaluation. The severity of an individual’s functional impairment is determined by an Examiner based on the results of an FCE.

Functional limitation. The inability to safely participate in work and/or other major life activities due to medically determinable impairment(s). Functional limitations are determined by an Examiner based on the results of an FCE.

Reference Tables

1. The Dictionary of Occupational Titles, 4th edition. U.S. Department of Labor. 1991.
2. Selected Characteristics of Occupations Defined in the Revised Dictionary of Occupational Titles. U.S. Department of Labor. 1993
3. Skilltran. Job Browser Pro. www.skilltran.com
4. Disability Evaluation. 2nd edition. American Medical Association. Mosby. 2003